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(� !0tE!R*l2X1! <br /> STATE ID NUMBER <br /> APPLICATIONFOR PERMIT TO ROUND STORAGE TANK <br /> 1 1 <br /> 01 NEW PERMIT l ) 05 RENEWED PERMIT Ts•,v r)nsFo f 1 09 DELETE FROM FILE (NO FEEI <br /> 1 ) 02 CONDITIONAL PERMIT l 1 06 AMENDED PERMIT A1,04 <br /> . <br /> I OWNER <br /> NAME(COPVORATION,INC IV IDUAI OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 01 FED 1 1 02 STATE f 1 03 LOCAL <br /> STREET ADDRESS CITY STATE IIP 2� <br /> l - /W-/IlL `(7� <br /> II FACILITY <br /> FACILITY NAME DEALER/FOPEMEN/SUPERVISOR <br /> _rArl S <br /> STREET ACD°ESS NEAREST CROSS STREET <br /> CITY COUNTY IIP <br /> MAILING ADDRESS — CITY f STATE Z. P <br /> PHONE WIAREA CODE TYPE OF BUSINESS /71 <br /> ( 1 <br /> 01 GASOLINE STATION L/';NO2 OTHER 6ft6lto& (SOU15:�7[Z6ij <br /> NUMBER CF CONTAINERSRVP AL AREAS ONLY TOWNSHIP vANGE SECTION <br /> III 2/+ HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAM,E(LAST NAME FIPST) AND PHONE W/APEA CODE NIGHTS: NAME)LAST NAME FIRST I-AND-PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 01 TALO( f 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG C. YEAR INSTALLED f 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER STORE= 01 HASTE ( ] 02 PRODUCT <br /> F. GOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 O1 YES 1 102 NO �I�F YES CHECK APPROPRIATE BOXIESI: <br /> 1 ) 01 UNLEADED ( 1 02 REGULAR ( 1 03 PREMIUM ( 1 04 DIESEL �S WASTE OIL lJC1 06 OTHER <br /> V CONTAINER CONSTRUCTION 1 <br /> A. TH ICY.NESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES f 1 CM �UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( 1 02 NON-VAULTED k,�f 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED ?13 02 SINGLE WALLED l 1 03 LINED D <br /> D. f 1 01 CARBON STEEL ( 1 02 STAINLESS STEEL f 1 03 FIBERGLASS ( 104 POLYVINYL CHLORIDE ( l 05 CONCRETE O4 <br /> ( ) 06 ALUMINUM 1 1 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> 2 UNKNOWN l 1 13 OTHER: <br /> HSC04-070185 <br /> ysC�4 <br /> I <br />